Correspondence to: Professor Jacqueline CT Close, Neuroscience Research Australia, University of New South Wales. Email: j.close@neura.edu.au

Abstract

Aim

To review the evidence regarding non-transported older people who have fallen in relation to non-transportation rates, outcomes and impact of alternate care pathways.

Method

Electronic databases and reference lists of included studies (up to December 2011) were systematically searched. Studies were eligible if they included data on non-transportation rates, information on outcomes or alternate care pathways for older people who have fallen.

Results

Twelve studies were included. Non-transportation rates following a fall ranged from 11% to 56%. Up to 49% of non-transported people who have fallen had unplanned health-care contact within 28 days of the initial incident. Attendance by specially trained paramedics and individualised multifactorial interventions significantly reduced adverse events including subsequent falls, emergency ambulance calls, emergency department attendance and hospital admission.

Conclusion

Limited but promising evidence shows that appropriate interventions can improve health outcomes of non-transported older people who have fallen. Further studies are needed to explore alternate care pathways and promote more efficient use of health services.

Background

Over 40% of older people experience a fall every year with many experiencing multiple and/or injurious falls [1] Increasingly, many of these falls result in a ‘triple zero’ emergency call and the subsequent dispatch of an emergency ambulance [2]. In New South Wales, Australia there were more than 42 000 emergency responses to older people who had fallen in 2008/09, constituting approximately 5% of the total annual emergency workload [3]. Falls in older people are therefore a significant contributor to emergency ambulance operational demand, which continues to increase at an alarming rate [4]. In most countries, current practice for ambulance service paramedics is to convey older people who have fallen to an emergency department (ED) unless the patient refuses to travel. Falls place a significant strain on ED resources, accounting for almost a fifth of ED presentations in older adults [5, 6]. EDs are also under significant time constraints and focus on dealing with the immediate consequences on the fall, with little consideration of a person's risk of future falls or appropriate prevention strategies. Despite evidence to support referral for comprehensive assessment following a fall [7, 8], currently few older people are referred for further interdisciplinary falls assessment and intervention following ED presentation [9].

Not all emergency ambulance responses result in patient transportation to hospital and a number of studies have been published on outcomes and related factors for older people who have fallen but not been transported to hospital [10-14]. In the absence of a physical injury, abnormal physiological parameters or a change in usual functional status, it could be argued that routine transportation by ambulance to the ED is not the most effective or efficient use of resources and that alternate models of care should be sought. These alternate care pathways for older people who have fallen are now being explored [12, 15], but data on safety and health outcomes of non-conveyed older people who have fallen are still limited.

This article systematically reviews the literature on older people who have fallen but are not transported to an ED after the emergency ambulance response. The aim is to summarise the evidence in relation to (i) non-transportation rates, (ii) outcomes following non-transportation, and (iii) outcomes from alternate care pathways for non-transported older people who have fallen.

Methods

Search strategy and selection criteria

Six electronic databases were systematically searched (Medline, Embase, CINAHL, PsycINFO, Cochrane Library and Web of Science) from inception until 31 December 2011. The following keywords and MeSH terms were used: ‘Emergency medical services’ AND ‘Accidental falls’, ((‘Emergency medical services’ OR ‘Ambulance’ OR ‘Paramedic’) AND (‘Accidental Falls’ OR ‘Fall’ OR ‘Falls’)) (Appendix I). Where possible, database search ‘limits’ were applied to select articles involving persons ‘aged 45+ years’ or ‘all adults’. The reference lists of articles considered for inclusion were also scanned for other potentially relevant studies. Publications in English and German were included and no other limits were applied.

Articles were included for review if they were peer-reviewed research publications and provided original data relating to non-transport rates for older people who have fallen (aged 60 years and older), either from a population sample or contemporaneous local or national health department statistics. Further, articles were included only if they provided information on outcomes following non-transportation for a fall, or outcomes for alternate care pathways for non-transported older people who have fallen. Studies were included if the majority of participants were 60 years or older.

All titles and abstracts were scanned independently by two investigators (AM and PS). Disagreements were referred to a third reviewer and resolved by discussion.

Extraction of data

Full-text articles were obtained for potentially eligible studies and data extracted independently by two reviewers, on study type and purpose, population demographics, non-transportation rates, reported outcome measures, and impact of any alternate referral pathways. Study quality or risk of bias were not assessed due to the variety in study designs included in this review. The level of evidence (LOE) for each included study was determined using the National Health and Medical Research Council (NHMRC) level of evidence classification system [16].

Results

Search results

Overall, 762 citations were identified and after adjusting for duplicates 642 remained, of which nine fulfilled the criteria for inclusion. Three additional articles were identified by searching the reference lists of included articles (Figure 1). In total 12 full-text articles about non-conveyed older people who have fallen were included for review [10, 12-15, 17-23].

The number of participants in the studies ranged from 70 to 3018 [15, 19]. Ten studies included only people aged 60 years and over [10, 12, 14, 15, 17, 19-23] with a mean age of 77 years, while two studies reported on people who have fallen of all ages, with a subgroup analysis of older people who have fallen [13, 18].

Non-transportation rate

Where data were available on non-transportation rates following a fall, this ranged from 11% (21) to 56% (17) (Table 1). Some studies that only included non-conveyed people who had fallen could not report a transportation rate but did report referenced contemporaneous local or national health department statistics, and these are included in Table 1.

Table 1. Characteristics and outcomes of included studies

Study

Study type and purpose

Population

Non-transportation rate

Outcomes following non-transportation

Impact of alternate care pathway

Level of evidence

Level of evidence: Type of study design; I: A systematic review of level II studies; II: A randomised controlled trial; III-1: A pseudorandomised controlled trial (i.e. alternate location or some other method); III-2: A comparative study with concurrent controls (e.g. non-randomised, experimental trial, cohort study, case–control study, interrupted time series with a control group); III-3: A comparative study without concurrent controls (e.g. historical control study, two or more single arm study, interrupted time series without a parallel control group); IV: Case series with either post-test or pre-test/post-test outcomes. IQR, interquartile range; SD, standard deviation.

Comparing transported and non-transported older people who have fallen.

Community dwelling

n = 485

88 non-transported older people who have fallen

397 transported older people who have fallen

Mean age: 82 years

(range: 66–97)

50 (57%) female

Stated non-transportation rate for people who have fallen for London Ambulance Service at the time of the study was 38%

Non-transported people who have fallen were shown to be at higher risk than transported people who have fallen – significantly older (82 vs 78 years), more likely to require an assistive device for mobilising (85% vs 37%) and less likely to be able to go outdoors alone (23% vs 79%)

Study to enhance the care of older people who were not transported to hospital after an emergency call.

Community dwelling

n = 89

Patients were reviewed using local falls risk assessment tool, received falls education (including environment checks) and rehabilitation (including mobility work and balance and gait training) via a rapid response team. Referrals were made to alternate health-care professionals as appropriate.

Age: 65+ years

Overall non-transportation rate for all age groups and conditions was 200/1000 during the 1 month pilot study (20%).

177/200 of those not conveyed were felt to require further assessment.

Examining differences in fall characteristics and emergency service response to older people who have fallen using personal alarms systems. Sub-analysis of older people who have fallen who used personal alarms compared with older people who have fallen who did not use a personal alarm.

Evaluation of a community-based fall prevention service offered to non-conveyed older people who have fallen to prevent subsequent falls.

Community dwelling and residential care facilities

n = 204

102 intervention – referral to community fall prevention services and seen within 12 days (IQR 4–26 days). Fall community team (physiotherapists, occupational therapists and nurses) provided individualised multifactorial intervention program

Reasons for non-transportation

In all studies, the final decision not to convey a patient was determined on scene by paramedics/emergency medical services in conjunction with the patient, but without further medical consultation. Numerous factors were suggested to explain/support a non-transport decision. Refusal to travel was the most common reason for non-transportation to ED/hospital [10, 13-15, 19, 22, 23]. Another common reason for non-transport to hospital/ED was if the patient did not sustain any injury or sustained only minor injuries [10, 13, 14, 17, 19, 20]. A number of articles described treatment on scene as ‘sufficient’ or that the person required ‘lift assistance only’ [13-15, 17-19]. Other reasons for non-transportation of patients included patients being referred to their GP [13, 15, 17, 22], or a negotiated shared decision for non-transport [22]. The study by Marks and colleagues, which included patients from all age groups also stated that in some cases patients made their own way to hospital or police or doctors continued patient care thus supporting non-transportation [13].

Outcome following emergency service response

Follow-up periods after initial emergency contact varied from 1 [15, 17] to 12 months [12, 22]. Seven studies collected information regarding non-transported older people who have fallen at one point in time and did not include any follow-up outcome measures [10, 13, 18, 20, 21, 23].

Studies which gathered information about ambulance re-attendance rates [12, 14, 15, 22], ED presentation rates [12, 14, 15, 17, 22] and hospitalisation [12, 14, 15, 17, 22] reported that non-transported people who have fallen were likely to access subsequent health care following the incident fall. Snooks et al. reported that 49% of non-transported people who have fallen had an unplanned health-care contact within 14 days including further emergency ambulance contact (22%) and ED attendance (24%) [14]. Gray and colleagues similarly reported 33% of initially non-transported people who have fallen attended ED and/or were admitted to hospital within 28 days of the incident fall [17]. Further, Vilke et al. reported that 13% of non-transported people who have fallen were subsequently conveyed to ED following a second emergency call and a further 13% made their own way to ED after the incident fall although the follow-up period for this study is unclear [22]. Studies reporting mortality rates found non-transported older people who have fallen to be at a significantly higher risk of death than their aged matched peers.

Alternate care pathways for non-transported older people who have fallen

Impact of different skill level at initial assessment

Gray et al. showed patients seen by emergency care practitioners (ECPs) had lower ED presentation rates and hospital admissions than those who received standard ambulance care. Fifty-six per cent of older people who have fallen who were seen by ECPs were not admitted to hospital within a 28-day follow-up period, compared with 48% of older people who have fallen treated by standard ambulance crews (P < 0.05) [17].

Availability of alternate referral pathways

When considering alternate care pathways, nine out of 12 studies showed non-conveyed patients were referred to other health-care providers, including GPs or primary care providers [10, 12, 14, 15, 17], community fall prevention teams [10, 12], district nursing [15, 20] or social services [12, 15, 19, 20] following emergency service attendance. Seven studies reported referrals being made at the time of paramedic attendance [10, 14, 15, 17, 22], while two studies initiated referrals as part of an intervention [12, 20]. Kue and colleagues initiated referrals to social services during paramedic attendance or within one week after chart screening if appropriate [19]. Onward referral rates varied from 33% [19] to 60% [20, 22], regardless of referral time.

Marks et al., who included all age groups in their study, showed poor paramedic referral rates with only 13% of patients being referred to GPs [13].

Impact of interventions

Prospective studies showed that interventions were able to significantly reduce adverse events [14, 15]. Studies that recorded patients’ contact with health practitioners/services [14, 15, 19, 22] noted GP contact was more likely and follow-up referral significantly higher [19] in the intervention group. Further, the number of subsequent emergency service calls was significantly lower in the intervention group [12].

Logan et al. [12] offered their intervention group an individualised multifactorial fall prevention program provided by community falls teams, consisting of occupational therapists (OT), physiotherapists (PT) and nurses. The intervention followed the UK clinical fall guidelines [24] and included training of strength and balance (led by a PT), assessment of home hazards and modifications to the environment (provided by an OT), and medication review and monitoring of blood pressure (completed by nurses). If required, participants were referred to other relevant health-care providers. Participants allocated to the control group were advised to use existing social and medical services as usual. The intervention group participants experienced significantly fewer subsequent falls (IRR 0.5; 95% CI: 0.4–0.6) and fewer emergency ambulance calls (RR 0.6; 95% CI: 0.4–0.9) than control group participants, who received standard emergency care. Further, the time to first subsequent fall was significantly longer in the intervention group (HR 0.3; 95% CI: 0.2–0.4). Intervention participants also scored significantly better on the Nottingham extended activities of daily living scale [25] at follow-up assessment, indicating a greater level of independence in activities (P < 0.001). A lower level of fear of falling using a falls efficacy scale (P < 0.001) was also reported by this group.

Mason et al. [15] conducted an RCT evaluating the effectiveness of paramedic practitioners attending older people in the community after minor injury or illness. Paramedic practitioners had received training to assess, treat and discharge older patients with minor acute conditions in the community; participants in the control group attended ED as per standard ambulance care following their emergency call. They found that intervention group patients had significantly lower ED attendance rates (RR 0.7; 95% CI: 0.7–0.8) and lower hospital admission rates within the first 28 days of the incident fall (RR 0.9; 95% CI: 0.8–0.9). Twenty-one per cent of the intervention group and 18% of the control group had unplanned contact with secondary care after the initial episode (RR 1.2; 95% CI: 1.06–1.4). Patients in the intervention group were less likely to report deterioration of their health during the follow-up period. These findings indicate that if older community-dwelling people with minor acute conditions are attended to by specially trained paramedics (ECPs), ED attendance can be reduced by almost 25% [15]. Both RCTs had active referral guidelines in place and reported high compliance with uptake of recommendations (Table 2).

Studies that included comparison groups found that, among patients who had fallen, those who were not transported to hospital were older, were more likely to be housebound and to require assistive devices, and performed worse on cognitive tests than those who were conveyed [10]. Personal alarm use was also associated with non-transportation; Johnston and colleagues noted that among patients who had fallen, 24% of those who used an alarm were not conveyed compared with 11% of those without personal alarms [18]. A study from the UK found that the time paramedics spent on scene was significantly longer when treating non-conveyed compared with conveyed participants [21]. This resulted in cost differences between these two groups although the total case cycle time for transported and non-transported people who have fallen was not considered.

Discussion

This systematic review of 12 studies examined factors related to non-transportation by ambulance services to ED of older people who have fallen. Major findings were that: non-transportation rates ranged from 11% to 56% and depended on the training level of the attending paramedics [15, 17]; non-transported individuals required substantial subsequent use of emergency ambulance services [12, 14, 15, 22]; and there is comparatively little evidence on the effectiveness of alternate models of care. The studies that followed patients after an emergency response revealed that these people are likely to suffer further falls and may benefit from an interdisciplinary assessment and intervention [14].

Non-transportation rate

It has been reported that up to 52% of all emergency service use including transportation to ED is ‘unnecessary’ or ‘inappropriate’ [14]. Commonly, non-transport is due to the paramedics not identifying an injury or the patient ‘refusing to travel’ against the advice of paramedics [10, 13, 15, 17, 19, 20, 22, 23] and many studies report that patients who appeared to respond well to medical treatment on scene are not transported [13-15, 17-19, 26].

Shaw and colleagues reviewed all refusal to travel patient documents and noted that 70% of those who refused to travel to ED had initially received medical treatment/management on scene, and that the most common management was a ‘lift assist’ [11], defined as ‘assistance in getting off the floor after a fall but not requiring any medical attention’ [19]. Of all patients categorised as refusing to travel, only 8% refused transportation against medical advice, while the remaining 92% were for reasons such as ‘no-injury’ or ‘good response to medical treatment received on scene’, indicating that the decision not to travel could be a negotiated one between paramedics and patients.

Paramedic decision-making regarding the need for transportation has been shown to be a complex process dependent on many factors including experience and confidence of ambulance staff, time factors, wishes of the patient, the presence of carers, waiting times at the local ED and knowledge of the patient from previous emergency attendances [27, 28]. Paramedics acting on clinical ‘intuition’ has been cited as an important element of paramedic decision-making; however, acting on intuition has been recognised as being a source of error and bias [29] and methods such as the use of an algorithm or ‘treat and release’ protocol are being promoted.

Dale et al. investigated, for patients of all ages, whether it was possible to determine the need for ambulance dispatch and paramedic attendance via computer assisted telephone advice [30]. However, this system proved to be deficient, in that more than 60% of patients triaged as not requiring an ambulance, were subsequently conveyed to hospital, and 25% of all calls prioritised as being ‘not serious’ were found to require immediate care.

Alternate care pathways for non-transported older people who have fallen

Many older people who call the ambulance are repeat callers with complex underlying health-care needs [20]. Metcalfe and colleagues suggested that if non-transported patients are followed up appropriately after an emergency response, the numbers of ED attendances could be drastically reduced. Emergency services are in a unique position both to assess and make recommendations for future management, but currently there are no protocols or recommendations available regarding onward referral for further assessment and management of falls risk [13, 19].

Multifactorial interventions have been shown to improve the outcome of people who have fallen who are seen and treated in ED [31] and a recent study undertaken in the UK provides evidence that an intervention offered to non-conveyed people who have fallen can make a significant and positive difference to patient health outcomes [12].

An alternative model of ambulance care that has good potential for managing older people who have fallen is the use of the ECPs. Originating in the UK, an ECP occupies a role between GP, nurse and paramedic. ECPs are trained to provide a more holistic approach to patient care, enabling them to assess, treat and refer clinically appropriate patients to primary care networks, avoiding unnecessary presentations at the ED [32-35]. Mason recently showed that paramedics with extended skills in working with older people in the community can provide a clinically effective alternative to standard ambulance transfer [15]. A similar model, called an ‘extended care paramedic’, has been developed in Australasia, with New South Wales, South Australia, and more recently New Zealand now running such programs [36].

It is important to ensure the decision not to transport an older person to hospital after a fall does not lead to a subsequent increase in unplanned health-care use. A third of the reviewed studies did not collect this information, making it difficult to determine the appropriateness of non-transportation. One study showed that 40% of patients required hospital admission within 28 days of the incident fall [15]. A study published in the USA showed that 70% of all patients who initially refused to travel and subsequently called the emergency service again within 48 hours were aged 60 years and over [37].

Limitations

This systematic review constitutes the most complete analysis to date of ambulance non-transport of, and outcomes for, older people who have fallen. However, we acknowledge it has certain limitations. The ambulance systems from which the results are drawn are operationally and clinically heterogeneous, which may explain the considerable variation in non-transport rates. Some of the key studies which provide the majority of the evidence regarding transport rates involved specialist paramedics (ECPs) whose clinical profile, training and non-transport activity are quite different from those of regular paramedics. Therefore, the transport rates achieved by these ECPs may not accurately reflect what is feasible within regular ambulance services. Secondly, only articles published in English and German were included in the search, which may restrict the generalisability of the study findings.

Conclusion

Despite a default of transportation to ED following an emergency ambulance call for most paramedics, the evidence suggests that up to half of older people who have fallen attended are not transported to EDs. Until recently decision-making has been a negotiated process between the paramedics and the patient. Clinical algorithms and decision support software are now evolving to support paramedics in the decision-making process about transportation but current systems lack clear onward referral pathways to ensure that this high risk older population receives appropriate assessment and intervention to prevent further falls.

Further research is needed to explore non-ED, alternate care pathways that can support ambulance services to make safe, efficient and clinically effective decisions around transportation by allowing timely access to assessment and intervention.

Acknowledgements

This study was funded by the NSW Health Promotion Demonstration Research Grants Scheme and we would like to thank them for their support.

Key Points

Protocols and clinical guidelines/recommendations are needed regarding onward referral of non-transported older people who have fallen in order to sufficiently assess and manage falls risk.

Emergency care practitioners, who have extended skills regarding older community-dwelling people who have fallen, can treat and refer appropriate patients to primary care networks thereby offering an alternative to standard ambulance care.

Limited evidence suggests that an individualised multifactorial intervention can significantly improve the outcome of non-transported older people who have fallen including reduced subsequent falls, emergency ambulance calls, emergency department attendance and hospital admission.

Further research regarding alternate care pathways available to non-transported older people who have fallen needs to be undertaken.

13Marks PJ, Daniel TD, Afolabi O et al. Emergency (999) calls to the ambulance service that do not result in the patient being transported to hospital: An epidemiological study. Emergency Medicine Journal2002; 19: 449–452.